FLORIDA – Remote Medical Review Supervisor

Job Overview

  • Specialty License RN
  • State License(s) FL

The Medical Review Supervisor supervises daily activities of medical review staff. As an essential function, this position is responsible for complying with IntegriGuards’ Corporate Compliance Program as it applies to the individual job duties, the department, and the company. This position will exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates, and/or agents.

Essential Functions:

  • Provides daily guidance to medical review staff, including reviewers and claims analysts, assigning workload.
  • Monitors overall workload to identify potential and actual backlogs. Works with Medical Review Manager to resolve and/or prevent work backlogs.
  • Oversees and reviews determinations in order to ensure the consistency of decision-making by medical review nurses and other allied health care professionals.
  • Participates in meetings with other medical review entities to discuss procedure and policy.
  • Review the QA results and, when needed, plans corrective action.
  • Maintains relationships with CMS. OIG, and the Affiliated Contractor, prime or subcontractors, including regular participation in conference calls.
  • Participates in and contributes to the quality management system.

Other Functions:

  • Performs other functions as assigned
Qualifications

 : Knowledge, Skills and Abilities:

  • Extensive knowledge of the Medicare program, particularly the coverage and payment rules.
  • Knowledge Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
  • General writing skills
  • Working knowledge of Microsoft Office, Internet and e-mail.

Work Conditions and Physical Demands:

  • Primarily sedentary work in a general office environment
  • Ability to communicate and exchange information
  • Ability to comprehend and interpret documents and data
  • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
  • Requires manual dexterity to use computer, telephone and peripherals
  • May be required to work extended hours for special business needs
  • May be required to travel at least 10% of time based on business needs

Certifications:(Required/Desired)

  • Active RN license in good standing.
  • Not currently sanctioned or excluded from any program operated by Federal or State Agencies including Medicare and Medicaid.

Minimum Education:

  • High School Diploma or GED required.
  • Bachelor’s degree in Nursing or related field preferred.

Minimum Related Work Experience:

  • Minimum of three years nursing experience
  • Minimum of two years supervisory experience in the area of medical/utilization review.
  • Shows longevity in employment with one or more past employers.

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.